St Paul Capitol at Home

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 38687 Based off observation and interview, the facility failed to ensure 1 of 1 storage room was maintained in a sanitary manner, where replacement dialysis machines were stored. Findings include: Observation on 7/18/24 at 7:57 a.m., of the storage room identified directly above where the replacement dialysis machines were stored was a small vent on the wall near the ceiling. Directly above that was a ceiling tile, that was boggy in appearance, and was heavily soiled with a brown, black, and fuzzy gray, mold-like residue. The vent was actively blowing air directly across the substance. Below that vent on the floor were 2 dialysis machines, that had been checked by Biomed and determined to be ready to replace a machine on the unit in case of equipment failure etc. Observation and interview on 7/18/24 at approximately 8:30 a.m., with the facility administrator assistant (AA)-A identified she agreed the substance was likely due to moisture and it would be blowing particles across the room and onto the clean dialysis machines. Staff would not normally re-disinfect the outside of those machines unless visible debris was present. Interview on 7/18/24 at 1:45 p.m., with the regional consultant and the facility administrator (FA) identified the FA had been aware of the tile and made a referral for maintenance to the nursing home (NH) who they rented space from to replace the tile approximately 1 week ago. The FA reported maintenance had fixed it after the above observations. The FA reported she had called the NH approximately 1 week ago, but had not advised staff to disinfect the machines if they were to require a machine to be put into service. Review of the 5/6/01, Infection Control for Dialysis Facilities policy identified cleaning and/or disinfection of equipment or work surfaces would be performed as soon as possible following exposure to blood or potentially infectious materials. There was no mention of any cleaning of disinfection of specific equipment that had been stored in the store room.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 38687 Based on observation ,interview, and document review, the facility failed to ensure 4 of 4 patients (P4, P2, P5, P6, and P9) washed their hands and/or access sites immediately upon arrival for dialysis treatment. Findings include: Observations on 7/18/24 from 6:15 a.m. to 7:30 a.m., identified 4 patients arrived for dialysis treatment. None of the patients washed their hands/access sites upon arrival before dialysis treatment. No staff were observed prompting patients to wash their hands and/or access sites upon arrival. There was no signage by the sink notifying patients to wash hands or applicable access sites. Interview on 7/18/24 at 10:15 a.m. with P9 identified he doesn’t routinely wash his hands upon entrance prior to dialysis treatment. Staff do not remind him. Review of the 7/18/24, patient list identified P4 and P2 had arteriovenous fistulas (AVF) (surgical connection between an artery and vein used for dialysis access), and P2 also had a central venous catheters (CVC) (catheter placed directly into a vein for dialysis access) as well as P5, P6, and P9 had CVC Interview on 7/18/24 at 9:40 a.m., with registered nurse (RN)-A identified P2 was hospitalized recently with an infection. Regarding washing their hands and/or access sites upon entering the treatment area for dialysis, RN-A noted patients should wash prior to treatment. She was aware some patients would not and would forget. She agreed staff should be prompting patients to wash, and if unable, staff should assist. She noted that did not always occur. Interview on 7/18/24 at 1:45 p.m., with the regional consultant and the facility administrator (FA) identified they agreed all patients should wash their hands and/or access sites if applicable upon entering the treatment room for dialysis. Review of the 5/6/01, Infection Control for Dialysis Facilities policy identified patients and caregivers were to be encouraged to wash their hands and access upon entry and prior to initiation of dialysis treatment.”